Basic Information
| Provider Information | |||||||||
| NPI: | 1093713331 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TKACH | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | KELLY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9600 BROADWAY EXT | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731147408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052309000 | ||||||||
| FaxNumber: | 4052309157 | ||||||||
| Practice Location | |||||||||
| Address1: | 9600 BROADWAY EXT | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731147408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052309000 | ||||||||
| FaxNumber: | 4052309477 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2005 | ||||||||
| LastUpdateDate: | 08/09/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 17380 | OK | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 100095900A | 05 | OK | MEDICAID | 200022041 | 01 | OK | RAILROAD MEDICARE | OTHER |